Mechanical pressure on the sole of an insensate foot is one of the most consistent drivers of diabetic foot ulceration and delayed healing. Despite advances in dressings, biologics, and surgical techniques, the single intervention with the most robust evidence base for closing a neuropathic plantar ulcer remains deceptively simple: take the load off the wound. The 2023 update of the International Working Group on the Diabetic Foot (IWGDF) offloading guideline, published in Diabetes/Metabolism Research and Reviews in 2024, reaffirms this principle and refines how clinicians should select among the available devices.
Why Offloading Matters
Diabetic peripheral neuropathy removes the protective pain signals that normally prompt a person to shift weight away from a damaged area. Repetitive plantar pressure, shear, and friction then perpetuate tissue breakdown and prevent re-epithelialization. Lazzarini and colleagues, in a 2024 systematic review and meta-analysis underpinning the IWGDF update, synthesized 194 eligible studies and consistently found that interventions which reduce and redistribute plantar pressure improve healing outcomes (Lazzarini et al., 2024). Offloading is therefore not adjunctive care for a plantar diabetic foot ulcer (DFU); it is the foundation upon which wound bed preparation, infection control, and vascular optimization are built.
The Hierarchy of Offloading Devices
First Choice: Non-Removable Knee-High Devices
The 2023 IWGDF guideline recommends a non-removable knee-high offloading device as the first-choice treatment for a neuropathic plantar forefoot or midfoot ulcer in a person with diabetes (Bus et al., 2024). Two options meet this definition: a total contact cast (TCC) or a removable cast walker rendered irremovable by the clinician fitting it (often with a wrap or cohesive bandage). The mechanical rationale is twofold. First, knee-high devices distribute load along the calf and reduce peak forefoot pressures more effectively than ankle-high alternatives. Second, and arguably more important, they enforce adherence. A meta-analysis cited within the guideline reported that non-removable devices were associated with a marked reduction in non-adherence (relative risk 0.07, 95% confidence interval 0.01–0.79).
A 2023 systematic review and meta-analysis by Yan and colleagues, published in Frontiers in Endocrinology, pooled twelve studies involving 591 patients and found that TCCs achieved higher healing rates (risk ratio 1.22, 95% CI 1.11–1.34) and shorter time to closure compared with removable offloading interventions (Yan et al., 2023). Reported 12-week healing rates with TCC reach approximately 90% in selected populations.
Second Choice: Removable Knee-High Devices
When a non-removable device is contraindicated—for example, in the presence of moderate-to-severe infection, ischemia requiring frequent wound inspection, or when the patient cannot tolerate full immobilization—the guideline endorses a removable knee-high device as the second-line option. Clinicians should reinforce, at every visit, that the device must be worn during all weight-bearing activity. Pedorthic and orthotic education at this stage materially affects outcomes, because removable devices only work when they are on the foot.
Third Choice: Footwear with Felted Foam
If neither non-removable nor removable knee-high devices are available or feasible, the guideline supports the use of appropriately fitting therapeutic footwear combined with felted foam padding around the ulcer. This is a pragmatic option in resource-limited settings, but the evidence supports it as inferior to higher-tier devices.
Adherence: The Hidden Variable
Even the best-engineered offloading device fails if it is not worn. A 2024 narrative review by Bus and colleagues on technological advances in offloading emphasized that wearable sensors, pressure-monitoring insoles, and smart cast technologies are emerging tools to track and improve adherence (Bus et al., 2024). Real-world studies of removable devices have repeatedly shown that patients wear them for only a fraction of weight-bearing steps, which helps explain the persistent gap between device efficacy in trials and effectiveness in everyday practice. Counseling patients about the dose-response relationship between wear time and healing—every step taken without the device is a step that delays closure—is a critical clinical conversation.
Special Situations
Hindfoot ulcers, ulcers in the setting of significant peripheral arterial disease, and Charcot neuroarthropathy require individualized offloading strategies that may include custom devices, instant total contact casts, or combinations with vascular intervention. The IWGDF practical guidelines stress multidisciplinary assessment in these cases (Schaper et al., 2024).
Clinical Summary
For a neuropathic plantar forefoot or midfoot ulcer, current evidence and international guidelines point in the same direction: a non-removable knee-high device, either a TCC or an irremovable walker, should be the default offloading choice. Removable knee-high devices are an acceptable second option when contraindications or intolerance exist, with adherence counseling. Therapeutic footwear with felted foam is a third-line strategy. Across all options, accurate device fitting, regular reassessment, and patient education remain the determinants that translate evidence into healed wounds.
References
- Bus SA, Armstrong DG, Crews RT, et al. Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2023 update). Diabetes/Metabolism Research and Reviews. 2024;40(3):e3647.
- Lazzarini PA, Raspovic A, Prentice J, et al. Effectiveness of offloading interventions for people with diabetes-related foot ulcers: A systematic review and meta-analysis. Diabetes/Metabolism Research and Reviews. 2024;40(3):e3650.
- Schaper NC, van Netten JJ, Apelqvist J, et al. Practical guidelines on the prevention and management of diabetes-related foot disease (IWGDF 2023 update). Diabetes/Metabolism Research and Reviews. 2024;40(3):e3657.
- Yan J, Liu Y, Zhou B, Sun M. Total contact casts versus removable offloading interventions for the treatment of diabetic foot ulcers: a systematic review and meta-analysis. Frontiers in Endocrinology. 2023;14:1234761.
- Bus SA, Armstrong DG, van Netten JJ. Offloading and adherence through technological advancements: Modern approaches for better foot care in diabetes. Diabetes/Metabolism Research and Reviews. 2024;40(6):e3769.
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